National TB Elimination Program (India)

National TB Elimination Program (RNTCP)
Country	India
Launched	1997
Website	tbcindia.gov.in Project Monitoring Portal

The National Tuberculosis Elimination Program (NTEP) is the Public Health initiative of the Government of India that organizes its anti-Tuberculosis efforts. It functions as a flagship component of the National Health Mission (NHM) and provides technical and managerial leadership to anti-tuberculosis activities in the country. As per the National Strategic Plan 2012–17, the program has a vision of achieving a "TB free India", and aims to provide Universal Access to TB control services. The program provides, various free of cost, quality tuberculosis diagnosis and treatment services across the country through the government health system.

Program Structure

The program is managed through a four level hierarchy from the national level down to the sub-district level. At the national level the program is led by the Central TB Division under the Ministry of Health and Family Welfare. The State TB Cell and the District TB Office governs the activities of the program at the state and district level respectively. At the sub-district/ Block level activities are organized under the Tuberculosis Unit. The Central TB Division is headed by a Deputy Director General - TB (DDG-TB) and is the National Program Manager. The administrative command falls to the Additional Secretary and Director General (NTEP and NACO) and the Joint Secretary-TB. Under the Central TB Division, a number of National Level Expert Committees and National Institutes for Tuberculosis, advise and assist in various programmatic functions. At the State level, a State TB Officer and at District level a District TB Officer manages the program .

Laboratory and Diagnostic Services

Diagnosis is made primarily based on sputum smear examination. X-rays play a secondary role in the standard diagnostic algorithm for pulmonary tuberculosis

Sputum smear microscopy, using the Ziehl-Neelsen staining technique, is employed as the standard case-finding tool. Two sputum samples are collected over two days (as spot-morning/morning-spot) from chest symptomatics (patients with presenting with a history of cough for two weeks or more) to arrive at a diagnosis. In addition to the test's high specificity, the use of two samples ensures that the diagnostic procedure has a high (>99%) test sensitivity as well.

As a national health program, RNTCP pays more attention to the sputum-positive pulmonary tuberculosis patients (who are likely to spread the disease in the community) than people with other, non-pulmonary forms of the disease.

Chest x ray and Catridge Based Nucleic Acid Amplification Test(CBNAAT) has been added recently,For PLHA(Patient Living With HIV AIDS) CBNAAT is the first choice of investigation,this test helps to detect the RIFAMPICIN resistant Mycobacterium TB within 2 hours

Treatment categories and drug regimens

Based on results from a recent study, RNTCP has issued guidelines to states on daily treatment for tuberculosis. The daily regimen will replace the existing alternate day (thrice weekly) regimen from January - February 2016 in selected states. The daily regimen has shown to be effective in reducing relapse rates and drug-resistance.

Standardized treatment regimens are one of the pillars of the DOTS strategy. Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, and Streptomycin are the primary antitubercular drugs used. Most DOTS regimens have thrice-weekly schedules and typically last for six to nine months, with an initial intensive phase and a continuation phase.

Based on the nature/severity of the disease and the patient's exposure to previous anti-tubercular treatments, RNTCP classifies tuberculosis patients into two treatment categories.

New*	Previously treated**
New sputum smear-positive, New sputum smear-negative, New extrapulmonary tuberculosis, others	Sputum smear-positive relapse, Sputum smear-positive failure, Sputum smear-positive treatment after default, others#
2H3R3Z3E3 + 4H3R3	2H3R3Z3E3S3 + 1H3R3Z3E3 + 5H3R3E3
2 months intensive phase + 4 months continuation phase Four drugs at Thrice-weekly Schedule for 2 months Intensive phase Two drugs at Thrice-Weekly Schedule for remaining 4 months continuation phase.	3 months intensive phase + 5 months continuation phase Five drugs at thrice-weekly Schedule for initial 2 months followed by Four drugs for next 1 month Intensive phase.Three drugs at Thrice-weekly Schedule for remaining 5 months continuation phase.

H: Isoniazid (600 mg), R: Rifampicin (450 mg), Z: Pyrazinamide (1500 mg), E: Ethambutol (1200 mg), S: Streptomycin (750 mg)

1. Patients who weigh 60 kg or more receive additional Rifampicin 150 mg.
2. Patients who are more than 50 years old receive Streptomycin 500 mg. Patients who weigh less than 30 kg receive drugs as per Pediatric weight band boxes according to body weight.

Notes

*New categories includes former Categories I & III

**Previously treated is former Category II

# Others include patients who are Sputum Smear-Negative or who have Extra-pulmonary disease who can have recurrence or resonance.

Public private partnership under RNTCP

In India a sizable proportion of the people with symptoms suggestive of pulmonary tuberculosis approach the private sector for their immediate health care needs. However, the private sector is overburdened, and lacks the capacity to treat such high volumes of patients. RNTCP-recommended Private-Provider Interface Agencies (PPIAs) help treat and track high volumes of patients through offering treatment vouchers, electronic case notification, and information systems for patient tracking.

Due to lacking training and coordination amongst private providers, adherence to the RNTCP protocol is quite variable amongst private providers, and less than 1% of private providers comply with all RNTCP recommendations. There is need for regularizing the varied anti-tubercular treatment regimens used by general practitioners and other private sector players. The treatment carried out by the private practitioners vary from that of the RNTCP treatment. Once treatment is started in the usual way for the private sector, it is difficult for the patient to change to the RNTCP panel. Studies have shown that faulty anti-TB prescriptions in the private sector in India ranges from 50% to 100% and this is a matter of concern for the healthcare services in TB currently being provided by the largely unregulated private sector in India.

Second phase of RNTCP

In the first phase of RNTCP (1998–2005), the programme's focus was on ensuring expansion of quality DOTS services to the entire country. The future holds a different set of challenges including MDR TB and HIV/TB

The RNTCP has now entered its second phase, approved for a period of five years from October 2006 to September 2011, in which the programme aims to firstly consolidate the gains made to date, to widen services both in terms of activities and access, and to sustain the achievements. The second phase aims to maintain at least a 70% case detection rate of new smear positive cases as well as maintain a cure rate of at least 85%. This needs to be done in order to achieve the TB-related targets set by the Millennium Development Goals for 2015 and to achieve TB control in the longer term. Today India's TB control program needs to update itself with the international TB guidelines as well as provide an optimal anti TB treatment to the patients enrolled under it or it will land up being another factor in the genesis of drug resistant tuberculosis.

History

India has had a TB Control Program since 1962. Since then it has re-organized itself two times; first into the Revised National Tuberculosis Control Program (RNTCP) in 1997 and then into the National Tuberculosis Elimination program in 2020.

National TB Program- NTP (1962-1997)

TB control efforts got organized with the National TB program (NTP) primarily focusing on BCG vaccinations as a preventive measure.

At that time, the Indian government lacked the financial backing to meet its public health goals. Therefore, external sources of funding and administration, often from the WHO and UN, became common in the realm of public health. In 1992, the WHO and Swedish International Development Agency evaluated the NTCP, finding that it lacked funding, information on health outcomes, consistency across management and treatment regimens, and efficient diagnostic techniques.

Revised National TB Control Program- RNTCP (1997-2020)

In order to overcome the lacunaesof the NTP , the Government decided to give a new thrust to TB control activities by revitalising the NTP, with assistance from international agencies, in 1993. Given TB's high curability rate 6-12 months after diagnosis, moving toward a clinical and treatment-based strategy was a sensible progression from the NTP. The Revised National TB Control Programme (RNTCP) thus formulated, adopted the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, as the most systematic and cost-effective approach to revitalise the TB control programme in India. DOTS was adopted as a strategy for provision of treatment to increase the treatment completion rates. Political and administrative commitment were some of its core strategies, to ensure the provision of organised and comprehensive TB control services was obtained. Adoption of smear microscopy for reliable and early diagnosis was introduced in a decentralized manner in the general health services. Supply of drugs was also strengthened to provide assured supply of drugs to meet the requirements of the system.

Large-scale implementation of the RNTCP began in late 1998.

Expansion of the programme was undertaken in a phased manner with rigid appraisals of the districts prior to starting service delivery. The initial 5-year project plan was to implement the RNTCP in 102 districts of the country and strengthen another 203 Short Course Chemotherapy (SCC) districts for introduction of the revised strategy at a later stage.

The Government of India took up the massive challenge of nationwide expansion of the RNTCP and covering the whole country under RNTCP by the year 2005, and to reach the global targets for TB control on case detection and treatment success. The structural arrangements for funds transfer and to account for the resources deployed were developed and thus the formation of the State and District TB Control Societies was under- taken. The systems were further strengthened and the programme was scaled up for national coverage in 2005.

This was followed up with RNTCP Phase II, developed based on the lessons learnt from the implementation of the programme over a 12-year period. The design of the RNTCP II remained almost the same as that of RNTCP I but additional requirements of quality assured diagnosis and treatment were built in through schemes to increase the participation of private sector providers and also inclusion of DOTS+ for MDR TB and also offering treatment for XDR TB. Systematic research and evidence building to inform the programme for better de- sign was also included as an important component. The Advocacy, Communication and Social Mobilization were also addressed in the design. The challenges imposed by the structures under NRHM were also taken into account. India achieved country wide coverage under RNTCP in March 2006.

The RNTCP was built on the infrastructure and systems built through the NTP. Major additions to the RNTCP, over and above the structures established under the NTP, was the establishment of a sub-district supervisory unit, known as a TB Unit, with dedicated RNTCP supervisors posted, and decentralization of both diagnostic and treatment services, with treatment given under the support of DOT (directly observed treatment) providers.

NIKSHAY, the web based reporting for TB programme has been another notable achievement initiated in 2012 and has enabled capture and transfer of individual patient data from the remotest health institutions of the country.

National TB Elimination Program- NTEP (2020-till date)

Consolidating a series of advancements of the RNTCP from 2016 onward, with the additional drive to achieve the END TB targets 5 years earlier, RNTCP was re-named as the National TB Elimination Program. The change came into effect from 1st January 2020 .This decision was declared by Special Secretary, Sanjeev Kumar, Ministry of Health and Family Welfare, in a letter to all the State Chief Secretaries.

See also

• Public health system in India
• Epidemiology of tuberculosis
• Tuberculosis management
• Tuberculosis diagnosis
• DOTS (Directly Observed Treatment, Short-Course)
• Stop TB Partnership
• Multi-drug-resistant tuberculosis

External links

• Nikshay, A web based solution for monitoring of TB patients to monitor RNTCP
• Tuberculosis Control India's Homepage on RNTCP
• National Institute of Research in Tuberculosis, Chennai Tuberculosis Research Center, Chennai
• NTI Bangalore The National Tuberculosis Institute, Bangalore